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Be Alert to Cancer Complications


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The proper place for this information was not clear to me, but since it has to do with staying well, the HEALTHY LIVING topic seemed appropriate. Hopefully, the correct choice was made in positioning it.

After reading this article, I realized that when Bill went to the ER recently, we were not fully aware of some of the complications that might occur when dealing with lung cancer, or cancer in general.

http://include.nurse.com/apps/pbcs.dll/ ... /frontpage


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There was a time when it was against the policies of some hospitals to admit patients with complications of cancer to the ICU because they basically had been given a death sentence. How times have changed.

"Today, 62% of patients diagnosed with cancer are alive after five years," says Brenda K. Shelton, RN, MS, CCRN, AOCN, a clinical nurse specialist at the Johns Hopkins Kimmel Cancer Center in Baltimore. "These patients are going to end up in the ICU more than ever before because there are now so many symptomatic support treatments for complications that there is confidence they can pull through." And, she says, "Many patients with cancer today are active, and you may not realize how quickly they can tip over the edge and end up in the ICU with a critical complication."

To care effectively for patients with critical complications of cancer, critical care nurses don't have to be experts in oncology, but they do need to become familiar with their local population of patients with cancer and the way those cancers and their treatments affect patients. Critical care nurses also should be aware of the types of cancers commonly treated at their facilities, as well as at other local and regional hospitals.

"You have to ask, 'Do we have a treatment for this particular complication here?' " says Shelton. "If you work in a hospital that does not have certain services [such as radiation therapy], you need to recognize that these patients must be referred out to a facility with those capabilities."

Two Common Emergent Cancer Complications

In superior vena cava syndrome, a common cancer, complication, a growing tumor or affected lymph node slowly compresses on the superior vena cava, which carries deoxygenated blood from the upper half of the body to the heart's right atrium. This results in an obstruction of blood return to the heart, causing raised venous pressure and interstitial edema.

"Patients usually present with a right-heart failure picture, including upper body edema that can be quite dramatic," says Shelton.

Progression of symptoms usually happens gradually as the tumor grows. Early symptoms may include puffy eyes or difficulty in buttoning a shirt because of edema of the neck. As tumor growth/invasiveness progresses, edema affects the entire upper body.

The condition can be life-threatening, and treatment can include upright positioning, intubation to stabilize the airway, bronchodialators, and thrombolytics if a clot is involved in the obstruction. Diuretics and steroids may be used to treat cerebral/airway edema. An endovascular shunt may be placed to relieve pressure on the vena cava. Cytoreductive therapy, including radiation and chemotherapy, may be initiated to shrink the tumor and thus relieve pressure on the vessel. Nurses should note IV lines should not be placed in the upper extremities because of edema and increased venous pressure, Shelton says.

Tracheobronchial obstruction cancer complications, on the other hand, can occur in the lower or upper airway. It most frequently arises in the upper airway from a newly diagnosed or progressing tumor, most commonly because of lung cancer. Tracheobronchial obstruction also can develop from a metastasis into the lung or chest from another area in the body.

Symptoms can include strider and hypoxia. To maximize air exchange, immediate treatment might include bronchodialators, steroids, and Heliox, a mixture of helium and oxygen.

"The reason these treatments come first is to stabilize the patient so you can assess the severity of the condition and so the patient can tolerate lying flat for a diagnostic CT scan," says Shelton.

Endotrachial intubation may be considered but it isn't effective if the obstruction is in the lower airway, because creative solutions may be necessary to stabilize an airway.

"I once took care of a patient who had such a big tumor in his chest that we positioned him on his belly so that the airway was above the mass instead of pressed underneath it," says Shelton.

More definitive palliative treatment can include radiation therapy or chemotherapy. It also is vital to consult an interventional bronchologist, who may be able to clear the airway using interventional techniques.

Other Critical Issues

Leukostasis is a cancer complication commonly seen in patients with leukemia, which causes excessive production of immature or dysfunctional leukocytes and results in the aggregation or "clumping" of these white blood cells.

The end result is organ failure. The two most important organs typically affected are the brain and the lungs, and patients can present with symptoms of respiratory distress, heart attack, or stroke.

Treatment may include cytoreductive therapies, such as chemotherapy and/or leukophoresis, the selective removal of large quantities of white blood cells from the blood. Shelton says, if possible, these patients should not receive blood transfusions, even if their blood counts are low, because transfusion could increase the risk of stroke and complicate finding a match for future bone marrow transplantation.

Tumor lysis syndrome is a cluster of complications that can develop secondary to the release of byproducts from the breakdown of dying cancer cells. Excessive byproducts lead to electrolyte imbalances, including hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia.

Tumor lysis syndrome happens most often in patients with lymphoma or leukemia. It generally develops after cancer treatment, when large numbers of cancer cells are dying. However, critical care nurses need to be aware that it can also develop after steroid treatment and can happen in any cancer patient without treatment at all.

Treatment includes meticulous electrolyte monitoring, hydration, and support for the rapid clearance of the byproducts of tumor lysis. This is done with early continuous renal replacement therapies, which are dialysis treatments provided continually, 24 hours per day.

With attention to the gems of care for today's patients with cancer, ICU nurses can help ensure the care — and quality of life — keeps pace with advancing treatments.

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(Nurse.com, October 20, 2008)


The information contained in these articles may or may not be in agreement with my own opinions. They are not being posted with the intention of being medical advice of any kind.

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  • 2 weeks later...
"Today, 62% of patients diagnosed with cancer are alive after five years," says Brenda K. Shelton, RN, MS, CCRN, AOCN, a clinical nurse specialist at the Johns Hopkins Kimmel Cancer Center in Baltimore.

Thanks Barb. The article makes me a little nervous if I ever turn out to be an emergency in my neck of the woods. But the above quote was music to my ears.

Judy in Key West

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